Please enable JavaScript.
Coggle requires JavaScript to display documents.
Group 3: Mind Map 5O y/o male with CHF right side - Coggle Diagram
Group 3: Mind Map
5O y/o male with CHF right side
Health History
Collection of Subjective Data
Past History
diagnosed with hyperlipidemia (5 yrs. ago)
diagnosed with hypertension (10 yrs. ago)
Patterns of Health Care
sedentary lifestyle
non-smoker
consumes alcohol occasionally
typically Western diet
Family History
Father had a heart attack at age 60 but no reported cardiovascular diseases
Present History
Chief Complaint
: "Napansin kong ambilis ko mapagod tsaka kapusin sa paghinga, tapos bigla ko na lang din napansin na medyo namamaga yung legs ko," As verbalized by the client.
Duration of Symptoms
: 6 months
Collection of Objective Data
IPPA Assessment Technique
Inspection
Peripheral Edema
: Assess for bilateral lower extremity edema.
Skin Changes
: Look for signs of venous insufficiency or peripheral arterial disease.
Palpation
Peripheral Pulses
: Assess for symmetry, amplitude, and presence of peripheral pulses (dorsalis pedis, posterior tibial).
Edema
: Palpate for pitting edema in the lower extremities.
Auscultation
Heart Sounds
: Assess for abnormal heart sounds such as murmurs, gallops, or rubs.
Lung Sounds
: Listen for crackles or wheezes indicative of pulmonary congestion or other respiratory issues.
Diagnostic Test/Examination/Procedures
Electrocardiogram (ECG)
:
To evaluate cardiac rhythm and detect any conduction abnormalities.
Echocardiogram
:
To assess cardiac structure and function, including left ventricular ejection fraction and presence of any valvular abnormalities.
Lipid Profile
:
To assess serum lipid levels, including total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides.
Renal Function Tests
:
To evaluate kidney function, as impaired renal function can contribute to fluid retention and exacerbate heart failure.
Tools and Equipment Used/Performed
Stethoscope
for auscultation.
Sphygmomanometer
for blood pressure measurement.
Echocardiography machine
for performing echocardiogram.
Electrocardiogram machine
for ECG recording.
Laboratory equipment
for analyzing blood samples for lipid profile and renal function tests.
Peripheral
pulse oximeter
for assessing oxygen saturation.
Medical/Surgical Interventions/Treatment
Medication Optimization
Addition of medications such as diuretics (e.g., furosemide) for fluid management if heart failure is diagnosed.
Adjustments to current medications (e.g., optimizing dosage of Lisinopril and Atorvastatin).
Referral to Cardiology
Consider referral to a cardiologist for further evaluation and management, especially if significant cardiac pathology is suspected.
Lifestyle Modifications
Encourage regular exercise and a heart-healthy diet low in sodium and saturated fats.
Patient Education
Provide education on medication adherence, lifestyle modifications, and recognition of worsening symptoms.